The nurse plans care to prevent a dangerous thermal environment for an older adult client who lives in a northern climate of the United States. Which client assessment data does the nurse recognize that can contribute to the risk of hypothermia? (Select all that apply.)
Has a history of alcohol abuse
Bathes three to four times a week
Has a history of diabetes mellitus
Becomes diaphoretic on warm days
is prescribed antidepressant
Has a history of a cerebrovascular accident CVA
Correct Answer : A,C,D,F
A. Has a history of alcohol abuse
Explanation: Alcohol can contribute to hypothermia as it causes vasodilation, leading to heat loss. It can impair the body's ability to regulate temperature.
B. Bathes three to four times a week
Explanation: While personal hygiene is important, the frequency of bathing alone may not be a direct risk factor for hypothermia. The overall environmental temperature and the individual's ability to regulate their body temperature are more critical considerations.
C. Has a history of diabetes mellitus
Explanation: Diabetes mellitus can increase the risk of hypothermia as it may affect circulation and peripheral nerve function. Impaired sensation and reduced blood flow can contribute to difficulty in maintaining body temperature.
D. Becomes diaphoretic on warm days
Explanation: Excessive sweating (diaphoresis) can contribute to the risk of hypothermia, as it leads to moisture loss from the skin, making it more challenging for the body to maintain a stable temperature.
E. Is prescribed antidepressant
Explanation: While certain medications, including some antidepressants, can affect thermoregulation, the prescription of an antidepressant alone does not necessarily indicate an increased risk of hypothermia. It is essential to consider the specific medication and its potential side effects.
F. Has a history of a cerebrovascular accident (CVA)
Explanation: Individuals with a history of a cerebrovascular accident may have impaired thermoregulation due to damage to the central nervous system. This can increase susceptibility to temperature extremes.
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Related Questions
Correct Answer is B
Explanation
A. Encouraging the client to use a cane when ambulating.
Explanation: Encouraging the use of a cane for ambulation can provide support and stability, aiding in fall prevention.
B. Keeping the side rails up on the client's bed at night.
Explanation: Keeping side rails up on the client's bed can pose a concern as it may increase the risk of entrapment and injury. Side rails can lead to accidental entrapment, and there is a potential for the client to try to climb over them, leading to falls or injuries. The use of side rails in older adults is a safety consideration that requires careful assessment and appropriate measures to prevent harm.
C. Keeping several low wattage night lights on in the evening.
Explanation: Using low wattage night lights is a good practice to enhance visibility and prevent tripping or stumbling in low-light conditions.
D. Installing wooden railings on the stairway to the bathroom.
Explanation: Installing railings on the stairway is a proactive measure to enhance safety and stability, especially in navigating stairs, and can contribute to fall prevention.
Correct Answer is D
Explanation
A. It provides monetary benefits to American citizens and legal residents to prevent their dependency on their families.
Explanation: Medicaid primarily provides health coverage rather than direct monetary benefits. Its focus is on ensuring access to medical care for those in need.
B. It provides a minimum level of economic support.
Explanation: While Medicaid may indirectly support individuals by covering medical expenses, its primary purpose is to provide health insurance coverage, not economic support in a general sense.
C. It is designed to help the states defray the expenses for the poor.
Explanation: This option describes the collaborative nature of Medicaid, where both federal and state governments contribute to funding. However, the primary goal is to provide health coverage to eligible individuals rather than defraying general expenses for the poor.
D. It is meant to provide insurance coverage for medical care to the older adult and disabled populations, regardless of their financial situations.
Explanation: Medicaid is a joint federal and state program that provides health coverage for certain individuals and families with low incomes, including older adults and people with disabilities. It is designed to assist individuals who may not have the financial means to afford necessary medical care. Medicaid covers a broad range of medical services, and eligibility is determined based on income, household size, and other factors.
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